Mary, gender identity is a person's internal sense of gender as name, female or something else. Everyone has a gender identity, just like everyone had a race. In most people, their gender identity matches the sex they were assigned at birth. For trans people, their gender identity does not match their sex assigned at birth.

Gender expression is the ways we express our gender toll the world through language, mannerisms, clothing, makeup, etc. These days, there are many people whose gender expression differs from what we might expect based on their sex assigned at birth, even though they are not transgender.

Actually the American Medical Association and every other major medical association, as well as the Medicare administration, say that hormones and other treatment for patients diagnosed with gender dysphoria are medically necessary, effective and appropriate. That's why Medicare now pays for surgery for transgender patients.

FYI, the HHS regulations are merely proposed at this pount. The public comment period ends on November 6. After HHS reviews the comments and makes any appropriate changes, the final regulations will be published and will become final 60 days later.